MINOR PROCEDURES FOR ED/URGENT CARE

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1 MINOR PROCEDURES FOR ED/URGENT CARE ELIZABETH BLUNT, RN, PHD, FNP -BC COLLEEN STELLABOTTE, RN, MSN, FNP -BC 1

2 Taser Removal 2

3 Taser Facts Brand name Electronic Control Weapon (ECW) Acronym from a 20 th century children s book Thomas A. Swift Electric Rifle Used to stun or incapacitate persons Provides a safer less than lethal force option 3

4 How Tasers Work Interferes with the ability of the brain to communicate with the muscles. Contacting the target on any body area leads to full incapacitation. Fires 2 small darts that act as electrodes Darts stay connected to the taser by thin conductive wires. When 2 darts stick a 5 second electrical charge is released. 4

5 Devices 5

6 Devices 6

7 7

8 How safe Extensive review of literature reveals injuries are associated with the fall and not from the electrical impulse. Do not cause cardiac arrhythmias when used appropriately and the exposure lasts for <15 seconds. High voltage with low wattage is the key to understanding the low electrical risk. Standard impulse setting is 5 seconds. Not risk free but a less lethal form of force. 8

9 Medical Considerations Threshold to induce ventricular fibrillation in a normal heart is joules. Most tasers fire at 0.5 joules or less. The most popular model fires at 0.3 joules, 30 times less than the threshold. High risk populations Pregnant women Elderly persons Young children Visibly frail Heart disease Medical/mental crisis Persons under the influence of alcohol/drugs 9

10 Assessment Confirm taser is off and cartridge is disconnected from the device. General survey of the patient addressing any serious injury from the fall. Evaluate the anatomical location of barbs. High risk zones Head Eyes Ears Nose Mouth Neck Genital Spine Hands, feet and joints 10

Barb Removal Universal precautions Local anesthetic Stabilize the skin surrounding the barb with your dominant using hemostats firmly grasp the barb with the notch facing up,

11 Barb Removal Universal precautions Local anesthetic Stabilize the skin surrounding the barb with your dominant using hemostats firmly grasp the barb with the notch facing up, jerk in a smooth quick motion Visually examine the barb to ensure it is fully intact Taser barb is considered a sharp, take all precautions to avoid accidental needle stick 11

12 Barb Removal Place barb in an appropriate container and return to law enforcement officer for evidence. Cleanse wound with antiseptic and dress. Up date tetanus immunization Instruct patient on basic wound care and signs and symptoms of infection. 12

13 Conclusion Current medical literature does not support the need for routine laboratory studies, electrocardiograms or prolonged ED observation after electrical exposure from a Electrical Control Device in an otherwise asymptomatic awake and alert individual. 13

14 ANIMAL BITE WOUNDS 14

15 EPIDEMIOLOGY Difficult to determine actual numbers because many are not reported CDC reports that an average of 4.5 million bites per year 885,000 require medical attention In 2006, 31,000 underwent reconstructive surgery Children are the most frequent victims 15

16 PRINCIPLES OF DISEASE Bites are traumatic injuries that cause damage to skin, muscle, nerves, blood vessels, tendons, joints and bones Wounds can be lacerations, contusions, scratches, tear or deep punctures Contamination with oral flora makes local wound infection the principle treatment concern along with rabies and tetanus immunization status Most US cities have animal bite reporting laws 16

17 CLINICAL MANAGEMENT Prevention and treatment of local bacterial infection and prevention, recognition and management of subsequent systemic illness Initial assessment for life threatening injury Meticulous exam and wound cleaning Special attention to wounds that involve joint space penetration 17

18 CLINICAL MANAGEMENT Facial, hands, and perineum wounds can be problematic due to the close proximity of delicate structures Image wounds if there is any suspicion of a foreign body Primary closure for cosmetic and functional issues Delayed primary closure is most successful Tetanus and Rabies immunization evaluation 18

19 HELICOPTER ACRONYM H E L I C O P T E R History Examination Liberal cleansing Irrigation Closure & culture consideration Operative cleansing and closure Prophylactic or therapeutic antimicrobial use Tetanus immunization status Elevation Rabies risk 19

20 TETANUS PROPHYLAXIS 20

21 RABIES PROPHYLAXIS Rare disease in developed countries Significant North American reservoirs of animal rabies exists in bats, skunks, raccoons and foxes. All carnivores and omnivores are potential vectors for updated information 21

22 RABIES PROPHYLAXIS DOG AND CAT BITES Condition of animal at time of attack Treatment of exposed person Healthy and available for 10 day observation No treatment unless animal develops rabies Rabid, suspected rabid, or escaped RIG and HDCV 22

23 RABIES PROPHYLAXIS Animal species Wild Skunk, bat, fox, raccoon, bobcat, and other carnivores Condition of animal at time of attack Regard as rabid Treatment of exposed person RIG and HDCV Bites from squirrels, hamsters, guinea pigs, gerbils, chipmunks, rats, mice, rabbits and hares almost never call for rabies prophylaxis. Consult local public health officials. 23

24 RABIES IMMUNOGLOBULIN (RIG) 20 IU/kg of body weight If anatomically feasible up to half the dose should be infiltrated around the wound and the rest administered in the gluteal area RIG should not be administered in the same syringe or into the same anatomic site as the vaccine because RIG may partially suppress active production of antibody 24

25 RABIES VACCINE (HDCV) HDCV 1 ml IM deltoid area on Day 0 Day 3 Day 7 Day 14 25

26 ANTIMICROBIAL TREATMENT All puncture wounds Bites involving hands, feet, face, or genital area Moderate or severe wounds All wounds in immunocompromised patients Bite wounds with signs of infection 26

27 PROPHYLACTIC ANTIBIOTICS Refer to the Sanford Guide to Antimicrobial Therapy or other source for specific bites Overall initial therapy for most bites and those not allergic to penicillin is Amoxicillin-Clavulanate Alternative combinations vary with specific animals 27

rabies exposure Consult local health department and

28 BATS Most recent human rabies has been caused by bats Contact with bats increases suspicion of rabies exposure Consult local health department and CDC Rabies is not transmitted by bat guano, urine or blood 28

29 DOG BITE 5-6 % become infected Pastaurella and anaerobes most common microorganism Capnocytophaga canimorsus rare but fulminant bacteremia following a dog bite 29

CAT BITES 60-80 % become infected Narrow sharp teeth increase the susceptibility to deliver infectious agents through

30 CAT BITES % become infected Narrow sharp teeth increase the susceptibility to deliver infectious agents through puncture wounds Pastaurella Multocida most common microorganism Cat scratch disease 7-12 days after bite or scratch 30

31 HUMAN BITES 31

32 HUMAN BITE WOUNDS AND CLOSED FIST INJURIES (CFI) Associated with a high incidence of infection, approximately 60%, especially with hand injuries Polymicrobial, staph and strept species Eikenella Corrodens common bacteria If blood involved hep B and HIV prophylaxis may be warranted CDC post exposure prophylaxis 24 hour hot line, for consultation 32

bacteriology of ferret bites CDC recommends management

33 FERRET BITES 3rd most popular pet in the US Usually attack face and neck Little is known about the bacteriology of ferret bites CDC recommends management strategy similar to that for other domestic animals, 10 day observation. 33

34 DOMESTIC HERBIVORES 34

35 HORSES AND PIGS Pigs and horses can inflict serious injury with their powerful jaws and grinding teeth Usually require careful debridement and exploration High risk of infection Polymicrobial 35

36 RODENT BITES Usually trivial No rabies Rat bite fever- 2 similar febrile illnesses diagnosis confirmed by blood culture for streptobacillus moniliformis or spirillum minus rare Hantavirus is also rare transmission 36

37 OPHTHALMOLOGY Anatomy External Lid Eyelashes Internal Cornea Conjunctiva Iris Limbus Sclera 37

38 OPHTHALMOLOGIC EVALUATION History Traumatic Atraumatic Red Flags Pain Visual disturbance Vital sign of the eye Visual acuity Snellen chart pt stands 20 ft from chart Hand held 13 inches 38

39 OPHTHALMOSCOPE Filter dial Large, medium small Half light Red free Slit beam Blue light Focusing wheel Positive focuses objects that are close Negative wheel focuses objects that are far away 39

40 SLIT LAMP Illumination system Bio microscope Basic goals r/o globe rupture, corneal abrasion, ulcerations, and foreign bodies Provides superior magnification Tangential lighting assists in the diagnosis of uveitis and iritis 40

41 EYE PRESSURES Indications Eye pain Eye trauma mmhg normal Numerous tools 41

Tonopen Anesthetize the eye Apply latex cover Calibrate unit if not already done (every 24 hours) Press activation switch, ==== appears indicating ok to test

42 Tonopen Anesthetize the eye Apply latex cover Calibrate unit if not already done (every 24 hours) Press activation switch, ==== appears indicating ok to test Probe is held like a pen, briefly and lightly touched to the cornea Do 4 times After 4 valid readings a final beep will sound and display an averaged measurement 42

43 Tonopen 43

volume, concentration, duration and mechanism Treatment

44 CHEMICAL BURNS Serious damage arises from strong basic and acidic compounds Severity is related to type of substance, volume, concentration, duration and mechanism Treatment goals- aggressive early management and close long term monitoring 44

45 Chemicals Acidic Battery acid (e.g., sulfuric acid) Bleach (e.g., sulfurous acid) Glass polish (e.g., hydrofluoric; behaves like alkali) Vinegar (e.g., acetic acid) Chromic acid (brown discoloration of conjunctiva) Nitric acid (yellow discoloration of conjunctiva Alkaline Cleaning products (e.g., ammonia) Fertilizers (e.g., ammonia) Drain cleaners (e.g., lye) Cement, plaster, mortar (e.g., lime) Airbag rupture (e.g., sodium hydroxide) Fireworks (e.g., magnesium hydroxide) Potash (e.g., potassium hydroxide) 45

46 MANAGEMENT Remove offending agent Irrigation Must contact ocular surface to be effective 1-2 liters Morgan lens Test ph Rx artificial tears Pain management Close ophthalmologic follow up 46

47 EYE FOREIGN BODY REMOVAL Topical anesthetic Measure visual acuity Inspect cornea If fb is visualized attempt removal with a moistened cotton-tip applicator If successful, fluorescein stain and inspect Evert upper lid to rule out pre-tarsal fb If unsuccessful refer to ophthalmology 47

48 EVERTING EYELID 48

inside the lower lid Instruct pt to blink Use a wood lamp,

49 FLUOROSCEIN STAINING Recommended for any red eye Procedure Grasp non-orange end Apply 1 drop of saline Gently place inside the lower lid Instruct pt to blink Use a wood lamp, blue filter on s slit lamp or a penlight with a blue filter 49

50 FLU0ROSCEIN STAINING 50

51 RING REMOVAL Remove all rings before edema!!!! Methods Lubrication String method Cut Consider anesthesia 51

52 RING CUTTER 52

STRING METHOD Wrap a Penrose drain circumferentially proximal to distal 20-25 in piece of string Pass

53 STRING METHOD Wrap a Penrose drain circumferentially proximal to distal in piece of string Pass string under ring Wrap proximal to distal not allowing any skin to protrude Grasp proximal end, turn clockwise 53

54 FISHHOOK REMOVAL 54

55 The Problem is. 55

56 Fishhooks Variety of shapes and sizes Barb is a projection extending backward from the point of the hook. 56

57 Fish Hook Removal Several methods for successful removal Strategy depends primarily on the depth of the hook Caution to be taken for removal of a hook with multiple barbs Anesthetize the area either locally or by a digital block depending on location 57

58 Simple Retrograde Technique Press skin over tip of hook to disengage barb while apply pressure downward on shank Back the hook out of the skin Most simple but least effective 58

59 String Pull Method Variation of retrograde technique String is wrapped around the bend of the hook where it enters the skin End of the shank is depressed with one hand to disengage the barb. The other hand gives a quick pull on the string 59

60 Needle Cover Technique Requires dexterity 18g needle is inserted into the entrance wound along side of the shank Needle follows the hook until the lumen covers the barb The hook and needle are withdrawn from the wound as a unit 60

61 Advance & Cut Technique Useful for deep penetration and large hooks Tip is advanced through the skin Once exposed tip and barb are cut with wire cutters The remaining part is rotated back out of the wound 61

62 62

63 Incision Technique Modified needle cover technique Used for hooks embedded in dermis or in delicate areas Enlarge of wound with a #11 scalpel, follow the bend of the hook until the barb is disengaged from the tissue Withdraw hook through the wound 63

64 Arthrocentesis & Joint Injection The Basics

65 Arthrocentesis Aspiration of fluid from a joint space May be diagnostic or therapeutic Generally presents few complications Joint injection may occur after fluid removal or may be performed as a separate procedure

66 Indications Diagnosis of non-traumatic joint disease Relief of pain Removal of effusion Local infiltration of medication Diagnosis of bony or ligament injury Establishment of intra-articular fracture Obtain fluid for culture & cell study

67 Contraindication Absolute Overlying infection Cellulitis Abscess Suspected bacteremia Steroid injection Septic joint Relative Recent fracture Osteoporosis Anticoagulants Bleeding disorders

68 Requirements Always ensure complete H&P before procedure X-Rays? Check for allergies Previous joint aspirations or injections? Informed consent

69 Decisions Aspirate? Inject? Both?

70 Fluid Analysis Observation Chemical Analysis Microscopic Study Bacterial Culture Serologic Study Polarized Light Microscope

71 Synovial Fluid Analysis Fluid grossly assessed as clear, turbid or bloody Most important to distinguish between inflammatory and infectious causes Normal synovial fluid is Straw, clear enough to read newspaper Flows freely consistency of motor oil Gives positive string test

72 String Test Simple test for fluid viscosity Viscosity correlates with hyaluronate Inflammation degrades hyaluronate which becomes lowers viscosity Measure fluid string from falling drop of gloved finger Normal fluid = 5-10cm string Inflammation = short string or multiple drops

74 Specimen Collection Cell count and cytology lavender top tube (EDTA) Chemistries, serology and viscosity red top tube ( no additive) Crystals green top tube(sodium heparin) or immediate visualization under microscope

75 Specimen Collection GC culture medium, low oxygen level Culture appropriate medium

76 Synovial Fluid Analysis Indicator Normal Inflammatory Infectious Gross Appearance Clear Transparent Yellow Clear-slightly turbid Yellow Cloudy String Sign Normal Diminished Diminished WBC/mm3 <200 <200 >2000 Culture Negative Negative >50% positive Crystals Negative Positive Negative

77 Common Joint Injection Sites Knee* Hip Ankle Shoulder* Glenohumeral joint Acromioclavicular joint Elbow* Lateral epicondyle Medial epicondyle Hand and Wrist Thumb* Trigger finger* wrist

78 Steroid Injection and Doses Preparation Large Joint Small Joint Triamcinolone hexacetonide 20mg 2-6mg Triamcinolone acetonide 20mg 2-6mg Prednisolone terbutate 25mg mg Betamethasone sodium 1ml ml Phosphate/acetate Methylprednisolone 35mg mg Triamcinolone diacetate 20mg 2-6mg Prednisone acetate 30mg 3-9mg

79 Frequency of Injection 6 to 12 weeks between injection No more than 3 times per year for large or weight bearing joints Inject no more than 3 separate joints per month

80 Equipment Sterile gloves Skin prep Iodine & alcohol Sterile 4x4 s Sterile towels Vapor coolant 1% or 2% lidocaine Non lock syringes 2ml, 10ml, 30ml Needles 18, 22, 25 gauge Hemostat 3-way stopcock Specimen equipment Steroid injection Sterile dressing

81 Stop Cock

82 Procedure Thorough H & P Position patient optimally Knee fully extended with relaxed quadriceps Elbow flexed 90 degrees, forearm pronated, palm flat on table Spend time to find anatomical landmarks!!!!!!

89 Procedure Aseptic technique Clip thick hair Area thoroughly scrubbed Bactericidal agent x 3 Medial to lateral aspect in circular motion Allow to dry between scrubs Clean area with alcohol Sterile gloves and equipment

90 Procedure Anesthesia for Site Vapor coolant 1% or 2% Lidocaine (rapid onset; 1-2 hrs) OR Bupivacaine (5 minutes; 2-4 hrs) OR Diphenhydramine OR Ice

91 Procedure Identify Landmarks!! Use larges practical needle 18 gauge aspiration 25 gauge for injection Use appropriate syringe 30cc or 60cc for aspiration Insert needle, pull back on plunger, enter joint space

92 Procedure Withdraw all fluid Use hemostat or stopcock to change syringe Assess fluid and transfer into container Cell count, culture, slide, string test If injecting change syringe and inject Withdraw needle and apply dressing

93 Potential Complications Infection Introduction Masking with steroid Steroid arthropathy Post injection inflammation (steroid flare hours)

94 Potential Complications Bleeding and blood vessel trauma Peri-articular complications Tendon rupture Soft tissue atrophy Systemic responses Elevated BS Peripheral flushing

95 Follow-Up Band-Aid Rest, Ice, Elevation, Compression Limited weight bearing for 48 hours Consider knee immobilizer NSAID or other analgesic Instructions for signs of infection

96 Conclusions When performed correctly, arthrocentesis is a relatively safe procedure that is used to obtain valuable diagnostic information and provide therapy for acute joint disease. The key to success is strict adherence to sterile technique, observance of anatomic landmarks and proper preparation of synovial fluid for examination.

97 Musculoskeletal Injuries Extremity X-Rays Splinting 97

98 MUSCULOSKETAL EVALUATION History!!!!! Traumatic vs atraumatic Mechanism of injury Physical Exam Diagnostics X-ray CT MRI 98

99 CLASSIFICATION OF SPRAINS/STRAINS Sprain- injury to the ligament that connects a bone to another Strain-injury to the muscle fibers and to other fibers that attach to the muscle. 1 ST DEGREE 2 ND DEGREE 3 RD DEGREE 99

100 OTTAWA ANKLE RULES 100

101 TYPES OF FRACTURES 101

102 RADIOLOGY HAND WRIST ELBOW KNEE ANKLE FOOT 102

103 MANAGEMENT P Protect from further injury. R Restrict activity. I Apply Ice. C Apply Compression. E Elevate the injured area 103

104 SPLINT INDICATIONS Sprain/strains Fractures Lacerations Inflammatory processes Infection/cellulitis 104

105 SPLINT MATERIAL Pre-formed Plaster Fiberglass 105

106 SPLINTING Upper extremity Volar Long posterior Sugar tong Thumb Spica Ulna gutter Finger splint Lower extremity Knee immobilizer Posterior leg Long Short Stirrup Cam boot Hard shoe 106

107 VOLAR 107

108 SUGAR TONG 108

109 THUMB SPICA 109

110 ANKLE STIRRUP 110

111 POSTERIOR LEG 111

112 KNEE IMMOBILIZER 112

113 ANKLE AND FOOT 113

114 COMPLICATIONS Ischemia Heat injury plaster Pressure sores Infection Dermatitis 114

115 Let s Splint 115

SESSION 2 8:45 10am. In-office Procedures. Contraindications to Injection. Introduction Joint and Soft Tissue Injection. Learning Objective

SESSION 2 8:45 10am. In-office Procedures. Contraindications to Injection. Introduction Joint and Soft Tissue Injection. Learning Objective SESSION 2 8:45 10am Procedures You Can Do In Your Office SPEAKER Roger W. Bush, MD, MACP Presenter Disclosure Information The following relationships exist related to this presentation: Roger Bush, MD,